Preoperative Simulation of Retropubic Midurethral Sling to Decrease Bladder Perforation Rate Among Obstetrics and Gynecology Residents.

IMPORTANCE: Bladder perforation is an often avoidable complication of retropubic midurethral sling procedures. Bladder injury rates decrease with surgeon experience, but literature on techniques to train novice surgeons is limited. OBJECTIVE: Our objective was to decrease the bladder perforation rate among obstetrics and gynecology residents during retropubic midurethral sling procedures through implementation of an instructional video and low-fidelity simulation. STUDY DESIGN: A baseline bladder perforation rate was determined by retrospective chart review. A prospective educational intervention, consisting of a 10-minute instructional video with preoperative simulation using a simple bony pelvis model, was then implemented among residents on the urogynecology service from December 2017 through March 2020. The primary outcome was the change in the bladder perforation rate. Compliance with the intervention protocol was a secondary outcome. Categorical data were evaluated using the χ 2 or Fisher exact test. Continuous variables were assessed using the Student t test or Mann-Whitney U test as appropriate. RESULTS: Two hundred fifteen retropubic midurethral sling cases were included in analysis. There were no significant demographic differences between the patients undergoing surgery preintervention and postintervention. Resident surgeons were in their second (47.4%) and third (52.6%) years of training. The postintervention bladder perforation rate was 6.5%, which is a 35% reduction from the preintervention perforation rate of 10% ( P = 0.19). The instructional video and preoperative simulation were successfully implemented in 193 of 215 (89.8%) eligible cases. CONCLUSION: Despite high compliance, the combination of the instructional video and preoperative low-fidelity bony pelvis simulation was not effective in reducing tension-free vaginal tape-associated bladder perforations among residents.

Risk Factors for Surgical Failure and Worsening Pelvic Floor Symptoms Within 5 Years After Vaginal Prolapse Repair.

OBJECTIVE: To assess independent risk factors for surgical failure and worsening pelvic floor symptoms within 5 years after vaginal prolapse surgery. METHODS: This secondary analysis includes OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) (n=374) and E-OPTIMAL (Extended) (n=285) trial participants. Surgical failure was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery or bothersome vaginal bulge. Worsening pelvic floor symptoms were defined as increases from baseline as large as the minimally important difference for subscale scores of the Pelvic Floor Distress Inventory: 11 for the Urinary Distress Inventory and Colorectal-Anal Distress Inventory and 34.3 for the Pelvic Organ Prolapse Distress Inventory. Outcomes were measured at 6 months then 1, 2, 3, 4, and 5 years. Chi-square and t test results from bivariate models and clinical relevance were used to inform final models. RESULTS: Baseline risk factors for surgical failure were Hispanic ethnicity (adjusted odds ratio [aOR] 1.92, 95% CI 1.17-3.15), perineal body (aOR 1.34, 95% CI 1.09-1.63), and pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 1.16, 95% CI 1.05-1.28). Risk factors for worsening of pelvic floor symptoms were pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 0.75, 95% CI 0.60-0.94) for worsening Pelvic Organ Prolapse Distress Inventory score, vaginal deliveries (aOR 1.26, 95% CI 1.10-1.44) and pretreatment Urinary Distress Inventory score (aOR 0.86, 95% CI 0.80-0.93) for worsening Urinary Distress Inventory score, and age (aOR 1.03, 95% CI 1.01-1.05) and pretreatment Colorectal-Anal Distress Inventory score (aOR 0.95, 95% CI 0.92-0.98) for worsening Colorectal-Anal Distress Inventory score. CONCLUSIONS: Hispanic ethnicity, larger preoperative perineal body, and higher pretreatment Pelvic Organ Prolapse Distress Inventory scores were risk factors for surgical failure up to 5 years after vaginal prolapse repair. Participants with higher baseline Pelvic Floor Distress Inventory scores were less likely to worsen. Risk factors for worsening Urinary Distress Inventory and Colorectal-Anal Distress Inventory scores included more vaginal deliveries and increased age, respectively. CLINICAL TRIAL REGISTRATION: NCT00597935, NCT01166373.

Prospective study of a single-incision sling versus a transobturator sling in women with stress urinary incontinence: 3-year results.

BACKGROUND: Long-term safety and efficacy data on use of single-incision slings in stress urinary incontinence are limited. OBJECTIVE: To determine whether the single-incision sling Solyx (Boston Scientific, Marlborough, MA) is noninferior to the transobturator sling Obtryx II (Boston Scientific) in efficacy and safety for treatment of stress urinary incontinence. This 522 post-market surveillance study has been designed in response to a Food and Drug Administration request to evaluate improvement in stress urinary incontinence at 36 months following single-incision sling compared with baseline, as well as provide an assessment of mesh-related complications and subject-reported outcomes, relative to the transobturator sling control. STUDY DESIGN: This prospective, nonrandomized, parallel cohort, multicenter postapproval study enrolled subjects to receive single-incision sling or transobturator sling. Study sites were assigned to a cohort group based on documented competency with the cohort device. Patient follow-up was 36 months to compare efficacy and adverse events for noninferiority. Inclusion criteria included stress predominant urinary incontinence, a positive cough stress test, and post-void residual ≤150 cc. Participants were ineligible if they had undergone previous stress urinary incontinence surgery or had a previous mesh complication. Primary endpoint was treatment success defined by composite negative cough stress test and subjective improvement in stress urinary incontinence using Patient Global Impression of Improvement at 36 months. Secondary endpoints included adverse events and indications for retreatment. Noninferiority margins of 15% and 10% were prespecified for the primary efficacy and safety endpoints. Data analysis was performed using intent-to-treat and per-protocol methods. Due to the observational nature of the study, a propensity score methodology was applied to account for differences in patient and surgeon characteristics between treatment groups. The study design and variables to be included in the propensity score model were reviewed and approved by Food and Drug Administration reviewers before outcome analyses were performed. RESULTS: No evidence of imbalance in baseline characteristics was observed between groups after propensity score stratification in the 281 subjects. EBL (72.3±92 vs 73.1±63.9 mL, P=.786), time to spontaneous void (1.1±2 vs 0.8±2.8 days, P=.998), and time to discharge (0.7±0.7 vs 0.6±0.6 days, P=.524) were similar between groups. At 36 months, treatment success was 90.4% in the single-incision sling group and 88.9% in the transobturator sling group (P=.93). At 36 months, mesh-related complications were similar between groups (mesh exposure: 2.8% vs 5.0%, P=.38). Serious adverse events including pain during intercourse (0.7% vs 0%, P=1.00), pelvic pain (0.7% vs 0%, P=1.00), and urinary retention (2.8% vs 4.3%, P=.54) were similar between groups. CONCLUSION: Single-incision sling was not inferior to transobturator sling for long-term treatment success of stress urinary incontinence. The rates of serious adverse events were acceptably low and similar between groups.

Rectal prolapse and urinary retention: A case report of an "anal cystocele".

BACKGROUND: Concomitant rectal and vaginal prolapse is diagnosed in 14-55% of patients who present for pelvic floor evaluation.Case: A patient was referred for pelvic floor evaluation in the setting of rectal prolapse and urinary retention. Preoperative magnetic resonance (MR) imaging revealed the presence of a posterior cystocele prolapsing through the full-thickness rectal prolapse. CONCLUSION: Rectal prolapse with concomitant urinary retention should raise suspicion for posterior bladder prolapse. Here we propose the new term "anal cystocele". MR imaging aids in the diagnosis and treatment planning for this condition.

Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications.

INTRODUCTION AND HYPOTHESIS: We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. METHODS: Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24 months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. RESULTS: Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12 months and overall improvement in bowel and bladder function. By 24 months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6 weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12 months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. CONCLUSIONS: Open sacrocolpopexy resulted in more successful prolapse treatment at 2 years.

Surgical Outcomes After Apical Repair for Vault Compared With Uterovaginal Prolapse.

OBJECTIVE: To retrospectively compare surgical success and complications between vaginal vault prolapse compared with uterovaginal prolapse in women who underwent apical prolapse repair for stage II-IV prolapse. METHODS: Women in one of three Pelvic Floor Disorders Network prolapse surgical trials were included. Absence of bothersome bulge symptoms, no prolapse beyond the hymen, and no subsequent prolapse treatment defined success and was our primary outcome. Secondary outcomes included comparison of quality-of-life measures, anatomic changes, and adverse events. Pelvic organ prolapse quantification (POP-Q) and quality-of-life measures were administered at baseline and 1-2 years postoperatively. Comparisons were controlled for study site, age, body mass index, baseline POP-Q, apical and anterior or posterior repair performed, and prior prolapse repair. Outcomes measured at multiple time points were analyzed using longitudinal models to assess whether differences existed across study follow-up. RESULTS: Four hundred twenty-one women underwent vault prolapse, and 601 underwent uterovaginal prolapse apical repair. The vault prolapse group was older, more likely to be white, and to have prior urinary incontinence or prolapse repair, stage IV prolapse, and more prolapse bother on a validated scale (all P≤.034). The vault prolapse group was more likely to undergo sacrocolpopexy (228/421 [54%] vs 93/601 [15%]); the uterovaginal prolapse group was more likely to undergo vaginal repair (508/601 [85%] vs 193/421 [46%] P<.001). There were no differences in success (odds ratio [OR] 0.76 for vault prolapse vs uterovaginal prolapse, 95% CI 0.51-1.15, P=.20), changes in Pelvic Organ Prolapse Distress Inventory scores (-79.4 vs -79.8, P=.89), postoperative POP-Q point C measurements (-7.0 vs -7.1 cm, P=.41), or serious adverse events (86/421 [20%] vs 90/601 [15%], P=.86) between groups. Among women who underwent a vaginal approach for repair of vault prolapse (n=193) or uterovaginal prolapse (n=508), there were no differences in success rates (OR 0.67, 95% CI 0.43-1.04, P=.09) at 1-2 years postoperatively. CONCLUSION: Surgical success of stage II-IV vault prolapse and uterovaginal prolapse apical repair was similar whether performed vaginally or abdominally at 1-2 years postoperatively.

Distance From Cervicovaginal Junction to Anterior Peritoneal Reflection Measured During Vaginal Hysterectomy.

OBJECTIVE: To quantify the distance of the dissection plane from the cervicovaginal junction to the anterior peritoneal reflection for vaginal hysterectomy. METHODS: This is a descriptive study examining the dissection plane for anterior colpotomy in 22 surgical patients undergoing vaginal hysterectomy and in nine cadaver specimens. Intraoperatively, the distance from the vaginal incision to the anterior peritoneal reflection was measured on the uterus after removal. In nine of these patients, this distance was also measured before anterior peritoneal incision. Embalmed cadavers with intact pelvic viscera were dissected and the distance of the same dissection plane was measured. RESULTS: Median (interquartile range) surgical patient age was 51.5 (42-63) years and the main surgical indications were abnormal uterine bleeding and pelvic organ prolapse. In these patients, the median (interquartile range) distance from cervicovaginal incision to anterior peritoneal reflection was 3.4 (2.6-3.7) cm. In cadavers, the median (interquartile range) age was 81 (72-86) years with a measured distance of 2.7 (2.4-2.9) cm. CONCLUSION: When performing a vaginal hysterectomy, surgeons can expect a median (range) dissection distance of 3.4 (1.8-4.6) cm from initial incision to the peritoneal reflection for anterior colpotomy.

Safety of Manual Morcellation After Vaginal or Laparoscopic-assisted Vaginal Hysterectomy.

UNLABELLED: STUDY OBJECTIVE: To determine the safety of manual vaginal morcellation by evaluating the rates of incidental uterine malignancy and manual vaginal morcellation after vaginal or laparoscopic-assisted vaginal hysterectomy. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University of Texas Southwestern Medical Center, Dallas, TX. PATIENTS: Women (n = 1,629) undergoing vaginal or laparoscopic-assisted vaginal hysterectomy. INTERVENTIONS: Vaginal hysterectomy (n = 1,091) or laparoscopic-assisted vaginal hysterectomy (n = 538) with and without scalpel morcellation. MEASUREMENTS AND MAIN RESULTS: The number of uterine malignancies, rate of vaginal morcellation, surgical indications, pathology diagnoses, and uterine weights were evaluated. Chi-square analysis was used to compare categoric data, and analysis of variance was used to compare uterine weights. There were no cases of leiomyosarcomas. There were 2 other sarcomas, 4 smooth muscle tumors of uncertain malignant potential, and 8 endometrial adenocarcinomas. The vaginal morcellation rate was 19.4%, but no malignancy was morcellated. Myomas were more common preoperatively and histologically in morcellated specimens. Mean (± standard deviation) uterine weights for morcellated versus nonmorcellated laparoscopic-assisted vaginal hysterectomy specimens were 285.5 ± 159.3 versus 140.1 ± 83.6 g (p < .001), respectively, and 199.9 ± 92.8 versus 111.9 ± 61.4 (p < .001), respectively, for vaginal hysterectomy. CONCLUSION: Vaginal manual morcellation is safe with a low risk of incidental malignancy. Variables that influence the decision for the vaginal approach may also affect malignancy risk and morcellation decisions. Thus, all patients undergoing vaginal or laparoscopic-assisted vaginal hysterectomy should be counseled regarding incidental malignancy, risk of morcellation, and alternatives for intact specimen removal.

Effects of preoperative local estrogen in postmenopausal women with prolapse: a randomized trial.

CONTEXT: Pelvic organ prolapse (POP) increases in prevalence with age; recurrence after surgical repair is common. OBJECTIVE: The objective of the study was to determine the effects of local estrogen treatment on connective tissue synthesis and breakdown in the vaginal wall of postmenopausal women planning surgical repair of POP. DESIGN: This was a randomized trial. SETTING: The study was conducted at an academic tertiary medical center. PATIENTS OR OTHER PARTICIPANTS: Postmenopausal women with a uterus and symptomatic anterior and/or apical prolapse at stage 2 or greater participated in the study. INTERVENTION: Estrogen (Premarin) or placebo cream for 6 weeks preoperatively was the intervention. MAIN OUTCOME MEASURES: Full-thickness anterior apical vaginal wall biopsies were obtained at the time of hysterectomy and analyzed for mucosa and muscularis thickness, connective tissue synthesis, and degradation. Serum levels of estrone and 17ß-estradiol were analyzed at baseline and the day of surgery using highly sensitive liquid chromatography-tandem mass spectrometry. RESULTS: Fifteen women per group (n = 30 total) were randomized; 13 per group underwent surgery. Among drug-adherent participants (n = 8 estrogen, n = 13 placebo), epithelial and muscularis thickness was increased 1.8- and 2.7-fold (P = .002 and P =.088, respectively) by estrogen. Collagen types 1α1 and 1α2 mRNA increased 6.0- and 1.8-fold in the vaginal muscularis (P < .05 for both); collagen type Ia protein increased 9-fold in the muscularis (P = .012), whereas collagen III was not changed significantly. MMP-12 (human macrophage elastase) mRNA was suppressed in the vaginal mucosa from estrogen-treated participants (P = .011), and matrix metalloprotease-9 activity was decreased 6-fold in the mucosa and 4-fold in the muscularis (P = .02). Consistent with menopausal norms, serum estrone and 17ß-estradiol were low and did not differ among the two groups. CONCLUSIONS: Vaginal estrogen application for 6 weeks preoperatively increased synthesis of mature collagen, decreased degradative enzyme activity, and increased thickness of the vaginal wall, suggesting this intervention improves both the substrate for suture placement at the time of surgical repair and maintenance of connective tissue integrity of the pelvic floor.

Cystolith formation complicating single-incision sling.

Single-incision slings are the newest midurethral slings developed for the surgical treatment of stress urinary incontinence. We report the case of a patient who underwent single-incision sling placement who presented with recurrent stress incontinence 3 years after the procedure. She was found to have a 1.7-cm bladder stone that formed around the single-incision sling polypropylene barb.

Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease.

OBJECTIVE: Use of robotically assisted hysterectomy for benign gynecologic conditions is increasing. Using the most recent, available nationwide data, we examined clinical outcomes, safety, and cost of robotic compared with laparoscopic hysterectomy. METHODS: Women undergoing robotic or laparoscopic hysterectomy for benign disease were identified from the United States 2009 and 2010 Nationwide Inpatient Sample. Propensity scores derived from a logistic regression model were used to assemble matched cohorts of patients undergoing robotic and laparoscopic hysterectomy. Differences in in-hospital complications, hospital length of stay, and hospital charges were assessed between the matched groups. RESULTS: Of the 804,551 hysterectomies for benign conditions performed in 2009 and 2010, 20.6% were laparoscopic and 5.1% robotically assisted. Among minimally invasive hysterectomies, the use of robotic hysterectomy increased from 9.5% to 13.6% (P=.002). In a propensity-matched analysis, the overall complication rates were similar between robotic and laparoscopic hysterectomy (8.80% compared with 8.85%, relative risk 0.99, 95% confidence interval [CI] 0.89-1.09, P=.910). There was a lower incidence of blood transfusions in robotic cases (2.1% compared with 3.1%; P<.001), but patients undergoing robotic hysterectomy were more likely to experience postoperative pneumonia (relative risk 2.2, 95% CI 1.24-3.78, P=.005). The median cost of hospital care was $9,788 (interquartile range $7,105-12,780) for robotic hysterectomy and $7,299 (interquartile range $5,650-9,583) for laparoscopic hysterectomy (P<.001). Hospital costs were on average $2,489 (95% CI $2,313-2,664) higher for patients undergoing robotic hysterectomy. CONCLUSION: The use of robotic hysterectomy has increased. Perioperative outcomes are similar between laparoscopic and robotic hysterectomy, but robotic cases cost substantially more. LEVEL OF EVIDENCE: : II.

Preventing L5-S1 discitis associated with sacrocolpopexy.

OBJECTIVE: To further characterize the anatomy of the fifth lumbar to first sacral (L5-S1) disc space and to provide anatomic landmarks that can be used to predict the locations of the disc, sacral promontory, and surrounding structures during sacrocolpopexy. METHODS: The lumbosacral anatomy was examined in 25 female cadavers and 100 computed tomography (CT) studies. Measurements were obtained using the midpoint of the sacral promontory as a reference. Data were analyzed using Pearson χ, unpaired Student's t test, and analysis of covariance. RESULTS: The average height of the L5-S1 disc was 1.8±0.3 cm (range 1.3-2.8 cm) in cadavers and 1.4±0.4 cm (0.3-2.3) on CT (P<.001). The average angle of descent between the anterior surfaces of L5 and S1 was 60.5±9 degrees (39.5-80.5 degrees) in cadavers and 65.3±8 degrees (42.6-88.6 degrees) on CT (P=.016). The average shortest distance between the S1 foramina was 3.4±0.4 cm in cadavers and 3.0±0.4 cm on CT (P<.001). The average height of the first sacral vertebra (S1) was 3.0±0.2 cm in cadavers and 3.0±0.3 on CT (P=.269). CONCLUSION: In the supine position, the most prominent structure in the presacral space is the L5-S1 disc, which extends approximately 1.5 cm cephalad to the "true" sacral promontory. During sacrocolpopexy, awareness of a 60-degree average drop between the anterior surfaces of L5 and S1 vertebra should assist with intraoperative localization of the sacral promontory and avoidance of the L5-S1 disc. The first sacral nerve can be expected approximately 3 cm from the upper surface of the sacrum and 1.5 cm from the midline. LEVEL OF EVIDENCE: II.

Endoanal ultrasound for detection of sphincter defects following childbirth.

INTRODUCTION AND HYPOTHESIS: The objectives of this study were to estimate the rates of sonographically detected anal sphincter defects within 72 h of childbirth and to evaluate intra- and interobserver agreement using three-dimensional (3-D) endoanal sonography data. METHODS: This is a prospective observational study of primiparous women delivered vaginally. Women without clinically identified anal sphincter lacerations underwent endoanal ultrasonography within 72 h of delivery. Intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was calculated using kappa statistics. RESULTS: The rate of sphincter defects in 107 women undergoing 3-D endoanal sonography was 12 %. Characteristics of women with sonographically detected sphincter defects, compared to those without, included a significantly increased rate of clinically diagnosed second-degree lacerations (54 vs 20 %, p 0.008). The intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was 0.82 [confidence interval (CI) 0.66-0.99] and 0.72 (CI 0.54-0.92), respectively. CONCLUSIONS: Anal sphincter defects detected using endoanal sonography are common, occurring in 12 % of primiparous women, and are significantly associated with other less severe perineal lacerations. Overall and combining sonographically detected defects with clinically diagnosed lacerations, we estimate that 17.8 % of primiparous women delivered vaginally sustain anal sphincter injuries. The intraobserver agreement for diagnosis of sphincter defects is very good and the interobserver agreement is good.

Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments.

INTRODUCTION AND HYPOTHESIS: Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients. METHODS: A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected. RESULTS: Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management. CONCLUSIONS: Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding.

STUDY OBJECTIVE: To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains. DESIGN: Systematic review. SETTING: Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options. PATIENTS: Women with AUB, predominantly from ovulatory disorders and endometrial causes. INTERVENTIONS: Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system. MEASUREMENTS AND MAIN RESULTS: Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found. CONCLUSION: Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Urodynamic indices and pelvic organ prolapse quantification 3 months after vaginal delivery in primiparous women.

INTRODUCTION AND HYPOTHESIS: This study aims to describe multichannel urodynamic indices and pelvic organ prolapse quantification (POP-Q) in primiparous women 3 months after vaginal delivery. METHODS: This was a secondary analysis of a group of women who had been randomized to either coached or non-coached pushing during the second stage of labor. Primiparous women were evaluated with POP-Q examination and multichannel urodynamic testing 3 months after vaginal delivery. RESULTS: Of 128 women evaluated, the cumulative stage of prolapse was distributed as 4.7% stage 0, 39% stage I, 56% stage II, and none with stage III prolapse or greater. For the anterior compartment, most had stage II prolapse. Stage I prolapse predominated for both the central and posterior compartments. Of the women, 14.1% had urodynamic stress incontinence, 12.5% had detrusor overactivity, and 6% had both. CONCLUSIONS: In a predominantly Hispanic primiparous population, ICS POP-Q stage II prolapse of the vagina, urodynamic stress incontinence, and detrusor overactivity are common findings at a 3-month postpartum assessment.

Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials.

OBJECTIVES: (1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions. STUDY DESIGN AND SETTING: Systematic review of English-language randomized controlled trials of AUB treatments in MEDLINE from 1950 to June 2008. All outcomes and definitions were extracted and organized into major outcome categories by an expert group. Each outcome was ranked "critically important," "important," or "not important" for informing patients' choices. RESULTS: One hundred thirteen articles from 79 trials met the criteria. One hundred fourteen different outcomes were identified, only 15 (13%) of which were ranked as critically important and 29 (25%) as important. Outcomes were grouped into eight categories: (1) bleeding; (2) quality of life; (3) pain; (4) sexual health; (5) patient satisfaction; (6) bulk-related complaints; (7) need for subsequent surgical treatment; and (8) adverse events. CONCLUSION: To improve the quality, consistency, and utility of future AUB trials, we recommend assessing a limited number of clinical outcomes for bleeding, disease-specific quality of life, pain, sexual health, and bulk-related symptoms both before and after treatment and reporting satisfaction and adverse events. Further development of validated patient-based outcome measures and the standardization of outcome reporting are needed.

Randomized trial comparing 2 fiber regimens for the reduction of symptoms of constipation.

OBJECTIVE: : This study aimed to compare the effects of a special bowel recipe with psyllium on symptoms of constipation. METHODS: : Women with symptoms of constipation were randomized to 6 weeks of either psyllium or a special bowel recipe. Patients completed a constipation scoring questionnaire and recorded characteristics of each bowel movement. RESULTS: : A total of 53 participants completed prestudy and poststudy constipation scoring questionnaires. Both groups demonstrated improvement in constipation scores (psyllium: 13.9 ± 4.7 to 9.0 ± 4.6, P < 0.001; recipe: 13.6 ± 4.1 to 8.5 ± 5.0, P < 0.001). Mean differences in pretreatment and posttreatment constipation scores were not statistically different between the 2 groups.Subjects taking the bowel recipe strained only 20% of the time compared with those using psyllium who strained 57% of the time (P = 0.007). Other symptoms improved from baseline, but the majority was not different between treatment groups. CONCLUSIONS: : The bowel recipe demonstrated no significant difference in efficacy to pure fiber.